Accreditation Compliance Manager

2 weeks ago

Houston, Texas, United States Nexus Health Systems Ltd Full time
Job Overview

POSITION SUMMARY:

Under the general guidance of the Corporate Director of Compliance, Risk & Quality, the Corporate Accreditation Manager is entrusted with the authority and responsibility to oversee, facilitate, and execute essential tasks aimed at achieving regulatory and accreditation objectives for the facility. This role acts as the primary liaison for both scheduled and unannounced onsite evaluations, regulatory preparedness, audits, and associated educational initiatives related to accreditation standards and compliance.

KEY RESPONSIBILITIES:

1. Oversee all accreditation activities across the system and propose strategies to enhance survey outcomes.

2. Lead documentation and analysis of accreditation activities, ensuring effective communication with relevant leaders.

3. Serve as the subject matter expert (SME) for DNV, CARF, Joint Commission, and RTC Minimum Standards, leveraging clinical and experiential knowledge to improve NHS programming and policies.

4. Cultivate and maintain professional relationships with key stakeholders and facility staff to foster collaborative communication and partnership in improvement initiatives.

5. Set work priorities and coordinate accreditation tasks to meet established deadlines.

6. Conduct accreditation tracer activities, encouraging participation, providing feedback, and suggesting improvements.

7. Deliver and oversee accreditation training for staff, engaging with medical personnel to ensure high-quality accreditation activities.

8. Plan and prepare audit and tracer initiatives that align with the quarterly or annual objectives set by NHS leadership.

9. Stay informed on accreditation information from authoritative bodies regarding local, state, and federal regulatory changes.

10. Collaborate with facility Directors and key personnel to ensure corrective action plans and improvement initiatives are progressing as intended.

11. Act as the SME and consultant across the system for survey guidance and planning.

12. Draft directives or assign projects to meet accreditation goals.

13. Present relevant information at facility Quality Councils or other committees as necessary.

14. Attend staff meetings and represent the Compliance & Quality Department of NHS professionally.

15. Perform additional duties as required by the facility or organization.

QUALIFICATIONS:

EDUCATION:

Associate degree in Nursing is required; a Bachelor's degree in nursing is preferred. Other degrees may be considered on a case-by-case basis.

EXPERIENCE:

Minimum of 3-5 years of recent hospital experience, preferably in acute care, long-term care, or rehabilitation settings. Demonstrated experience leading accreditation surveys and activities is essential. A minimum of 1 year in a healthcare quality, compliance, or patient safety department is preferred, with alternate experience considered on a case-by-case basis. Experience managing cross-departmental projects in a matrix structure is preferred. A strong understanding of Quality Management System (QMS) principles is advantageous.

LICENSURE/CERTIFICATION:

Unencumbered Registered Nurse (R.N.) license in the State of Texas or another compact state is preferred. Basic Life Support (BLS) certification is required. CPHQ or equivalent healthcare certification is required or must be obtained within 12 months of hire.

KNOWLEDGE, SKILLS, AND ABILITIES:

Advanced proficiency in MS Outlook and MS Office is required. Experience in navigating and interpreting medical records is essential. Extensive knowledge of healthcare standards, including CMS, JC, DNV, and CARF is necessary. Excellent project management skills, presentation abilities, and proficiency in audit tools and tracers are required. A working knowledge of pediatric care and related sub-specialties is beneficial. Advanced verbal and written communication skills are crucial for effective collaboration in a team environment and meaningful contributions to projects.

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